Healthcare Provider Details

I. General information

NPI: 1992646251
Provider Name (Legal Business Name): HEATHER PEDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2028 2ND AVE NW
WEST FARGO ND
58078-1317
US

IV. Provider business mailing address

2028 2ND AVE NW
WEST FARGO ND
58078-1317
US

V. Phone/Fax

Practice location:
  • Phone: 218-356-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL12846
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: